SYMHC Classics: Flexner Report

This 2020 episode covers the Flexner Report, which is often credited with changing the medical field and shaping what medical education looks like today. But this document negatively impacted medicine in the Black community. See omnystudio.com/listener https://omnystudio.com/listener for privacy information.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

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• 2:58Holly Frey?

  Happy Saturday. One of our upcoming episodes talks about someone who went to medical school at a time when medical education in the US could be all over the place. So today's Saturday classic is about that, and about a report that was part of a shift toward medical schools that were more standardized and comprehensive.

• 3:18Tracy V. Wilson?

  That was the Flexner Report, and our episode on it and its author originally came out on July 8, 2020.

• 3:28Holly Frey?

  Welcome to Stuff You Missed in History Class, a production of iHeart Radio.

• 3:38Holly Frey?

  Hello and welcome to the podcast. I'm Holly Frey.

• 3:41Tracy V. Wilson?

  And I'm Tracy V. Wilson.

• 3:43Holly Frey?

  Tracy, one of the topics that's come up a couple of times for me in recent weeks is I've just been doing my own reading related to racial injustice, is the Flexner Report. And this was a report that was issued in the early 20th century. It is often credited with changing the medical field and shaping what medical education looks today. I also found one article that said it's the most overrated document in medical history, which made me laugh a bit.

• 4:05Tracy V. Wilson?

  Oh, goodness.

• 4:07Holly Frey?

  But there are also aspects of this document that really need to be discussed in terms of how they impacted the Black community. So we're going to talk about this one in three parts. First, we're going to talk about Abraham Flexner, for whom the report is named, and who made the report. And then, we're going to talk about the general impact of the Flexner Report on medicine. And finally, we will talk about how this affected Black medical schools specifically. And it is a lot to unpack, and I hope we manage to do it justice, as with anything related to any of these topics, a person's biography, the history of any given field, and the history of how things impact racial injustice. Like, there are always more nuances than we could ever pack into an episode, but we're hoping we hit all of the prominent and pertinent points.

• 4:52Tracy V. Wilson?

  Yeah. If you listen to the podcast Saw Bones, they did an episode, which I guess at this point will be a few weeks ago, that was about racism in medicine. And it alludes to this without going into much detail about it. So if you listen to our show and that show, these are sort of...

• 5:09Holly Frey?

  They'll complement one another.

• 5:11Tracy V. Wilson?

  They do. They do. We didn't plan that. It just happened. So this starts with Abraham Flexner. And Abraham Flexner was born in Louisville, Kentucky on November 13, 1866. His father, Moritz Flexner, and his mother, Esther Abraham, were German Jewish immigrants. Moritz had a hat business, and Esther worked as a seamstress.

• 5:34Holly Frey?

  The Flexner family was large. Abraham was their sixth child, and they ultimately had nine. Moritz and Esther were able to build up their finances with the plan not that they would live lavishly, but that every one of their sons, and there were seven of them, would attend college. But that plan fell apart when the 1873 panic hit and they lost their savings.

• 5:56Tracy V. Wilson?

  But Abraham did manage to go to college. He attended Johns Hopkins University, and the funds came from his brother Jacob. The span and the ages of the Flexner children meant that Jacob was already established by the time Abraham graduated from high school. And the money he was making as a drugstore owner was put toward Abraham's tuition.

• 6:16Holly Frey?

  Yeah, they definitely always prioritized that education is where they put their money. Abraham earned his BA in 1886, and his hope had been to go into a postgraduate program. But there was not enough money for that. And though he did try to secure a fellowship, none materialized. So he went home to Louisville to start his career.

• 6:38Tracy V. Wilson?

  For the next four years, Flexner worked as a high school teacher, heading up the Latin and Greek classes at Louisville High School. But during that time, he was developing another idea because he thought there was a better way to structure education.

• 6:51Holly Frey?

  And that idea manifested as an experimental school, and Flexner founded that school in 1890. That school was simply called Mr. Flexner School, and it was incredibly progressive. The structure probably seemed like no structure at all to traditional educators. Flexner did away with the idea of a set curriculum. Students did not have exams, and they did not receive grades. The vision that Flexner had for this school was custom-tailored education to prepare students for higher learning. And a lot of his students got into very good schools, so this was a very successful model.

• 7:26Tracy V. Wilson?

  The Flexner family continued to value education and help one another in that regard. One of the personal benefits for Abraham Flexner in creating his school was that he could enroll his brother Simon there and get him into Johns Hopkins. He was also able to pay for Simon's tuition. Abraham also helped his sister Mary. He paid her way at Bren Mar. This marks an expansion of the family's plan to not only educate the men of the family, but also the women. And education for women was something that Abraham supported throughout his life.

• 7:57Holly Frey?

  One of the former pupils in Flexner's preparatory school, a young woman named Anne Crawford, also became an important part of Abraham's life. After graduating, Anne had become a teacher. She had attended Basser, and when she finished those studies, she started working there at the school. And she also had started to pursue a career as a playwright. Abraham and Anne fell in love, and they were married in 1898. And they eventually had two daughters, Jean and Eleanor.

• 8:23Tracy V. Wilson?

  In 1904, Anne adapted the novel Mrs. Wiggs of the Cabbage Patch, which was a comedic story about an impoverished Southern family, into a Broadway play. Mrs. Wiggs ran from September 3, 1904, through January 1905 at the Savoy Theater, and it was a success. The income from Anne's work on the show made it possible for Abraham to enroll at Harvard to get his master's degree in psychology. He closed his school to do that. He also spent a year in Germany as part of his studies, again bankrolled through his wife's success in the theater.

• 8:57Holly Frey?

  That time spent in Germany made Flexner deeply aware of what he saw as the failings of the education system back home. And as a result, in 1908, he researched and wrote an assessment of higher education in the United States titled, The American College: A Criticism.

• 9:14Tracy V. Wilson?

  Based on his work examining colleges and identifying what he saw as the problems at the single school level, as well as systematically, Flexner was commissioned by the Carnegie Foundation for a new project. He was asked by the president of the Carnegie Foundation for the advancement of teaching, that was Henry Smith Pritchett, to apply that same critical and analytical eye to the medical institutions, specifically in the United States and Canada. There were 155 medical schools in his survey.

• 9:46Holly Frey?

  Yeah, he took two years to basically travel around and visit all these schools and do his assessment. And then in 1910, Flexner completed his report, which was titled, Medical Education in the United States and Canada. And when this report came out, it had a massive impact on medical education in North America. A lot of the schools that Flexner had found lacking closed as a consequence of its publication. Others were completely overhauled and essentially rebuilt from the ground up. And we're going to talk more about all of that in just a moment.

• 10:17Tracy V. Wilson?

  Following the medical school report, Flexner produced a report at the behest of the Rockefeller Foundation examining the sex work field in Europe and how it was regulated. It was the first of many varied reports that Flexner would compile for the foundation.

• 10:32Holly Frey?

  But though he had moved on to other projects like that, Flexner did not just drop his medical report and then move on with his life. He actually dedicated himself to improving medical education specifically.

• 10:44Tracy V. Wilson?

  In 1913, following his report on European sex work, Flexner became the secretary to the Rockefeller Foundation's General Education Board. During this time in his role, he worked on a number of other research and reporting projects, as we mentioned, but he also made sure that money from private donors was allocated to medical education and improving some of the problems he had discovered while working on his 1910 report.

• 11:10Holly Frey?

  In 1921, Abraham Flexner wrote a memo for the Rockefeller Foundation's board, which was titled "The Usefulness of Useless Knowledge." And this memo evolved, and it became a lecture. And then 18 years after he initially wrote it, it was published in Harper's Magazine. And that piece of writing opens with the following paragraph, quote, "Is it not a curious fact that in a world steeped in irrational hatreds which threaten civilization itself, men and women, old and young, detach themselves wholly or partly from the angry current of daily life to devote themselves to the cultivation of beauty, to the extension of knowledge, to the cure of disease, to the amelioration of suffering,

• 11:52Holly Frey?

  just as though fanatics were not simultaneously engaged in spreading pain, ugliness, and suffering? The world has always been a sorry and confused sort of place, yet poets and artists and scientists have ignored the factors that would, if attended to, paralyze them. From a practical point of view, intellectual and spiritual life is, on the surface, a useless form of activity, in which men indulge because they procure for themselves greater satisfactions than are otherwise obtainable. In this paper, I shall concern myself with the question of the extent to which the pursuit of these useless satisfactions proves unexpectedly the source from which undreamed-of utility is derived."

• 12:34Tracy V. Wilson?

  One of the things that Flexner touches on in this writing is the unintentional outcomes of pursuits that were of pure intent. He specifically mentions how the advancement of the cruelty of warfare was fueled by scientists who were often working, they thought, for the betterment of mankind.

• 12:52Holly Frey?

  As the 1920s wore on, Abraham Flexner found himself at odds with other members of the Education Board at the Rockefeller Foundation. And this led to him ultimately being pushed out of the organization in 1928.

• 13:05Tracy V. Wilson?

  In 1929, Abraham Flexner was approached by philanthropist siblings Louis and Caroline Bamberger. The Bambergers thought they could use their wealth to establish a new medical school in Newark, New Jersey, and they wanted Flexner as an advisor on the project. But Flexner pointed out that Newark had neither a teaching hospital nor a top-notch university, both of which were vital to the success of a medical school.

• 13:31Holly Frey?

  And Abraham Flexner was really thinking of a different sort of project. And he was able to convince the Bambergers that they should instead invest in his idea. And they did, with a gift of $5 million. Flexner envisioned what he would later call "an educational utopia" that offered the greatest minds a place where they could be driven entirely by their curiosity.

• 13:52Tracy V. Wilson?

  And so in 1930, Flexner founded the Institute for Advanced Study in Princeton, New Jersey, and served as director there until 1939. Its mission stated, quote, "The institute is pledged to assemble a group of scientists and scholars who, with their pupils and assistants, may devote themselves to the task of pushing beyond the present limits of human knowledge and to training those who may carry on in this sense."

• 14:18Holly Frey?

  Flexner was able to attract some of the biggest names to his institute, including Albert Einstein, who joined in 1933. In the years since its founding, the institute has had, as members or as faculty, 34 Nobel laureates, 42 Fields medalists, and 18 Abel Prize laureates. In addition to Einstein, notable names on that list include Robert Oppenheimer and previous podcast subject John von Neumann.

• 14:44Tracy V. Wilson?

  We're going to cover the end of Flexner's life and the impact of his work on medical education, but we're due for a quick break to have a word from our sponsors.

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• 20:39Holly Frey?

  The same year that he opened his institute, Abraham also published another book about education. This time, it was a comparative review of how schools ran in different countries titled Universities: American, English, German.

• 20:53Tracy V. Wilson?

  Flexner retired as director at the institute in 1939 after an internal conflict in which the school was accused of allowing an anti-Semitic climate at Princeton, a school that they routinely worked with. They were allowing that climate to hinder the work of a lot of the professors. As tensions among the scholars and leadership wore on, Flexner retired in the autumn of 1939. Although he was in his 70s, he stayed very busy after leaving the institute, consulting on various projects and writing several books, including his autobiography.

• 21:26Holly Frey?

  During and after World War II, several of Abraham's siblings died. By the end of the 1940s, only Abraham and his sister Gertrude were still living out of the nine Flexner siblings. At the same time, his wife Anne had gradually developed vascular dementia. In 1947, Anne had declined so seriously that she was taken to a Rhode Island sanitarium. Their two daughters frequently visited her, and they updated their father, but Abraham never saw Anne again. He had not coped with her illness well and could not bear to have the person that he had been so close to no longer recognize him. He later told friends that he had actually had a breakdown during this time.

• 22:06Tracy V. Wilson?

  As he recovered from this significant change in his life, Flexner moved to a hotel near Central Park and enrolled in classes at Columbia. He opted for classes in literature and history. In 1951, The New York Times read an article about the 85-year-old Flexner, educational reformer, taking classes alongside coeds a quarter his age.

• 22:27Holly Frey?

  Anne died shortly before Abraham's 90th birthday, which once again sent him into a dark period. And as he was slowly returning to his old self, his daughter Jean convinced him to leave New York and move to Falls Church, Virginia, which is where she lived, so that he could be near her. And he spent two years there, enjoying a very active social life and visiting the museums of nearby Washington DC regularly before his death on September 21st, 1959.

• 22:53Tracy V. Wilson?

  So moving on to his report about medical schools, as we mentioned, Flexner covered 155 schools in his 1910 report. And in researching that report, he had visited each school and written detailed and comprehensive notes about their entrance requirements, faculty, funding, laboratories, and connections with affiliated hospitals. In the five decades before his research, massive advances in science and medicine had been made, but because there was no comprehensive guidance for how medical schools operated, a lot of them were still teaching out-of-date information, basically telling future doctors stuff that wasn't believed to be true anymore. This was in large part because the faculty at many medical schools consisted largely of practicing physicians

• 23:38Tracy V. Wilson?

  who were teaching exactly as they had been taught without updating that information with the changing times.

• 23:45Holly Frey?

  Bacteriology, diagnostic developments, and surgical techniques were all rapidly changing fields. And if a school wasn't keeping up, the doctors they trained were in danger of offering their patients poor or outdated care at best and endangering their lives at worst.

• 24:01Tracy V. Wilson?

  To compound that problem, there were a lot of new medical schools opening with totally varied standards for entry. When Flexner published his study, 74% of the medical schools that were open required only a high school education for admission. Some were willing to accept high school equivalency certificates, which meant that there was really no clear standard. Only a fifth of the schools required two or more years of college prior to entry. Many were essentially profit-driven businesses.

• 24:32Holly Frey?

  Abraham Flexner was also very frank in his report about how little the public really knew about the workings of any given medical school. He wrote in the introduction, quote, "Educational institutions, particularly those which are connected with a college or a university, are peculiarly sensitive to outside criticism and particularly to any statement of the circumstances of their own conduct or equipment, which seems to them unfavorable in comparison with that of other institutions. As a rule, the only knowledge which the public has concerning an institution of learning is derived from the statements given out by the institution itself, information which, even under the best circumstances, is colored by local hopes, ambitions, and points of view."

• 25:17Holly Frey?

  Flexner felt that this work was vital and important to be doing, writing that the information in it was of importance not just to medical practitioners, but to, quote, "every citizen of the United States and Canada."

• 25:29Tracy V. Wilson?

  Abraham Flexner, building on standards that were already in place in Germany, established standards of evaluation for the medical schools in his study and then judged each one against those criteria. And we should note that he was not the first person to do this in the United States. The Association of American Medical Colleges, founded in 1876 and consisting of 22 member schools, had agreed on curriculum standards to provide uniformity in medical education. That had happened after an assessment of the state of medical education. The AAMC continued to grow and reevaluate in the years between its founding and Flexner's report. The American Medical Association had similarly started issuing reports

• 26:11Tracy V. Wilson?

  on the status of medical education as early as 1848. And some of the criteria they used were present in Flexner's evaluation system as well. But neither of these had oversight over all medical schools. It was an opt-in on a set of standards.

• 26:28Holly Frey?

  All of Flexner's work was aimed at determining, in his opinion, whether a school was able to effectively teach its students modern medicine. The model that he drew up for what this looked like included admittance requirements of college-level biology, chemistry, and physics courses, a curriculum with both lecture and lab teaching of anatomy, pathology, bacteriology, and pharmacology, among other courses, access to teaching hospitals for hands-on experience, salaried faculty who were exclusively working in teaching and research, not practicing doctors who just taught on the side.

• 27:05Tracy V. Wilson?

  Flexner laid out his findings state by state and school by school. He was detailed, calling out if he had found dirty labs or lacked standards. He criticized the way the days were scheduled at schools and how exhausted students were often sitting through hours of dull lectures by part-time faculty. Because he was an outsider, an education reformer, rather than a member of the medical community, his assessment was without preconception, and it was brutally honest, offering the general public a startling look at the way people who cared for their health were being educated.

• 27:38Holly Frey?

  Flexner advocated for state licensing boards to take a more assertive role in modernizing medicine by refusing to license graduates from schools that were not up to standards. And he believed that a lot of schools were not up to standards. In the end, he recommended that 120 of the 155 he reviewed for the report should be closed. That recommendation was based on his assessments that their standards were very poor and that they were not keeping up scientifically and thus were creating poorly educated doctors who lacked up-to-date knowledge in their field, which was something he saw as a completely obvious danger to public health. Canadian schools, we should mention, fared much better than their US counterparts overall.

• 28:20Holly Frey?

  Only one school there made Flexner's list of closing recommendations. It was not closed, though they did have a little bit of a review of their curriculum and their standards and changed up a little.

• 28:31Tracy V. Wilson?

  Many of the schools in the US that he recommended be closed did close. Within a decade, there were only half as many medical schools as there had been when Flexner's report was published. Those that had remained had reformed their standards and their courses and their lab work and clinical teaching had been significantly changed and in most cases, modernized. For all of the change that was catalyzed by the report, Flexner became famous as an educational reformer.

• 28:59Holly Frey?

  We're going to pause here before we dig into the ramifications of Flexner's work for Black medical schools specifically. So here, in the meantime, are some of the sponsors that keep Stuff You Missed in History Class going.

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• 31:02Speaker 02

  This new chicken nugget, reinvented based on real feedback, is made with 100% white meat chicken and is now better than ever. You gotta try the new Burger King Chicken Nuggets and sauces today.

• 31:16Tracy V. Wilson?

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• 32:00Tracy V. Wilson?

  and find people who can help drive results. Spend less time searching and more time actually interviewing candidates who check all your boxes. Less stress, less time, more results. Get your $75 sponsored job credit today at indeed.com/podcast. Terms and conditions apply. Hiring now, then this is a job for Indeed Sponsored Jobs.

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• 33:18Speaker 06

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• 33:49Holly Frey?

  Talk to your doctor. Call 1-800-545-5979 or visit zepbound.lily.com. We've all done it, tumble down an internet rabbit hole trying to self diagnose. And sometimes doing our own research can leave us more anxious than informed. Your feed is packed with wellness trends telling you to cold plunge, protein max, detox, track your sleep. But what's actually real? What's exaggerated? What's just wrong? That's exactly what Health vs. Hype from the American Medical Association and iHeartMedia's Ruby Studio is here to find out. Each episode, Emmy nominated science communicator Trace Dominguez, who's racked up billions of views across PBS, Discovery Channel,

• 34:33Holly Frey?

  and YouTube, talks to doctors, influencers, and real people trying these trends. Not to cancel them, not to hype them more, but to actually understand them. Because when it comes to your health, who you listen to matters. Start asking better questions and listen to Health vs. Hype on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

• 35:05Holly Frey?

  Before we talk about the effects of the Flexner Report on the black population in the US and its medical schools, we should give a brief sense of what was going on in that space prior to 1910.

• 35:16Tracy V. Wilson?

  The first black man in the US to receive a medical degree was David J. Peck. He received a degree from Rush Medical School in Chicago in 1847. As a note, he was not the first black doctor in the US. That's usually cited as formerly enslaved James Durham. He was born in 1762 and learned medicine through an apprenticeship. In the 13 years after Peck's graduation, there were a handful of other black med students who graduated with degrees in the US. Nine medical schools had established that they would admit black students by 1860, including the Medical School of Harvard, of Harvard University, Bowdoin Medical School in Maine, and the Medical School of the University of New York.

• 36:00Holly Frey?

  In the late 1860s, the first medical school for black students opened. That was Howard University Medical School in Washington DC, and it opened in 1868. Eight years later, Maheri Medical College opened in Nashville, Tennessee. From 1876 to 1904, another six black medical schools opened, including Leonard Medical School, which became Shaw University in Raleigh, North Carolina, New Orleans University Medical College, Knoxville College Medical Department, that became Knoxville Medical College, Chattanooga National Medical College, and University of West Tennessee College of Physicians and Surgeons.

• 36:36Tracy V. Wilson?

  The schools listed there are ones that were opened when Flexner compiled the report. There had been others that had folded before the 1908 research started. That included Lincoln University in Oxford, Pennsylvania, which had opened in 1870 and closed four years later. Straight University Medical Department was established in New Orleans in 1873, but was disbanded in 1874. Hannibal Medical College of Memphis, Tennessee, had opened in 1889, but closed in 1896. Louisville State's University Medical Department ran from 1899 to 1903. Chattanooga National Medical College closed in 1904, after five years in operation.

• 37:17Holly Frey?

  The Medical Society of the District of Columbia was founded in 1817. That society was for whites only. The American Medical Association was founded in 1847. And though black doctors applied to become members, for years, they were denied entry. We're going to come back to the AMA in just a bit. The Medico-Terurgical Society was founded as a black medical society in 1884 because of the impossibility that black doctors faced gaining admittance to those established groups. The National Medical Association was founded in 1895 for black doctors for the same reason. It was not until the 1950s that black doctors had gained admittance to medical societies in most states.

• 37:59Tracy V. Wilson?

  In the midst of this clear division and racism, the Flexner Report was released. Flexner had often been lauded for his role as a reformer. And as we've discussed, reform did need to happen. He was obviously blunt and often scathing in his critiques of individual schools. And the schools for black med students were no different. In his report, he wrote, quote, "Of the seven medical schools for Negroes in the United States, five are at this moment in no position to make any contribution of value." While he praised both Howard and Maheri as worth developing, the rest were deemed basically useless. This assessment did not take into account the fact that black medical schools charged much lower tuition than white schools,

• 38:42Tracy V. Wilson?

  had fewer endowments, and were operating on much narrower margins.

• 38:46Holly Frey?

  In his assessment, he wrote, quote, "The Negro needs good schools rather than many schools." He went on to elaborate that it was important for black doctors to be well educated. He understood that black doctors would see to the health of the black population. And since the black population was a part of the larger whole, their care was important. But the language that Flexner used throughout this section, where he talked about all of this, is a very mixed bag. He simultaneously speaks of the rights and contributions of black people, but also asserts that it is best if black doctors take care of their own people and offers the teaching of hygiene as one of the most important duties of black doctors and nurses, rather than life-saving skills, which is just inherently racist.

• 39:31Tracy V. Wilson?

  Every black medical college that Flexner called out as subpar, closed. The first four had shut their doors by 1914. The fifth closed in 1915. The last from the last list, the Medical Department of the University of West Tennessee, lasted until 1923. Howard and Maheri remained, and they still do. The Charles Ardrue Medical School in Los Angeles was the next predominantly black medical school to open. That didn't happen until 1966. Listen to our episodes on Brown v. Board. Like, that seems late in the creation of a medical school.

• 40:08Tracy V. Wilson?

  But that school was founded like specifically to respond to, to medical access needs within the black community. The next was Morehouse School of Medicine in Atlanta in 1975.

• 40:19Holly Frey?

  So the narrowing of options for prospective black doctors left a huge care gap for the black community. Many potential physicians were excluded from educational opportunities due to location, which meant that the care of black patients was often doled out by white doctors who even in the best of circumstances, met their duties with inherent racial bias. And as we have discussed on the show before, there were definite racist abuses of power in the medical system, and this has had far reaching and ongoing consequences.

• 40:50Tracy V. Wilson?

  A panel was assembled by the American Medical Association's Institute for Ethics in 2005 to examine the history of racism in the medical profession. One of their findings was that the Carnegie Foundation's project for which they hired Flexner, that had been sponsored by the AMA as well, although that hadn't been disclosed at the time. Flexner's line of good schools rather than many schools had ensured that medicine stayed segregated and that communities who needed doctors the most were just left without them.

• 41:21Holly Frey?

  Yeah, there are some question marks that continue about whether or not someone associated with the AMA was actually with him on some of those school visits. And at some points in history, he said that that person was with him. And then later on, he was like, no, no, no, no, no. Like they met me there. Like it, it shifted. So we don't really know if there was even more hands on direction of that report in that regard or not. A lecture on the now defunct black med schools by Dr. Earl H. Harley of Washington DC was published in the Journal of the National Medical Association in September of 2006. And in it, Dr. Harley summarized how black medical schools, which have always been smaller, with a higher percentage of graduates going into medicine for underserved communities,

• 42:05Holly Frey?

  have continued to face obstacles in the century since Flexner's report, writing, quote, "One of the greatest challenges of today's black medical schools is economics. Black medical schools find it difficult to compete with well-funded majority universities with a longstanding commitment to train African Americans, such as the University of Michigan. The result may be the siphoning of well-qualified, highly competitive African American students who choose, quote, 'rich schools for pragmatic economic reasons.' This places an extra burden on today's black medical schools of appealing to a higher social calling as they seek to fulfill their historic missions. While they search for greater endowments to become more attractive, they must continue to position themselves as the training grounds for those

• 42:50Holly Frey?

  who will serve the underserved."

• 42:52Tracy V. Wilson?

  So this brings up a natural question. Did Flexner realize the disproportionate impact of his report on black med students and doctors and patients? He spoke at length about race throughout his life, but what were his intentions with this 1910 report? And I mean, apart from his attentions, the effects that we just mentioned?

• 43:12Holly Frey?

  Yeah, but we don't know what his mindset was. And there are different schools of thought on it. You can talk to a lot of people and they will give you completely different answers for whether or not they thought that there was racism in the mix or if Flexner really understood this. He did know that he was limiting the scope of black medicine. He said so in his report, although it is part of a rather idealist passage that reads, quote, "The upbuilding of Howard and Mahary will profit the nation much more than the inadequate maintenance of a larger number of schools. They are, of course, unequal to the need and opportunity, but nothing will be gained by satisfying the need or of rising to the opportunity through the survival of feeble, ill-equipped institutions,

• 43:55Holly Frey?

  quite regardless of the spirit which animates the promoters."

• 43:59Tracy V. Wilson?

  In 1930, Flexner wrote a letter to the trustees of his Institute for Advanced Studies in which he advocated against discrimination, quote, "It is fundamental in our purpose and our expressed desire that in the appointments to the staff and faculty, as well as in the admission of workers and students, no account shall be taken, directly or indirectly, of race, religion, or sex. We feel strongly that the spirit characteristic of America at its noblest, above all the pursuit of higher learning, cannot admit of any conditions as to personnel other than those designated to promote the objects for which this institution is established, and particularly with no regard, whatever, to accidents of race, creed, or sex."

• 44:41Holly Frey?

  It appears that Flexner's progressive ideas about equality, particularly in relation to race, probably came from his childhood in Louisville. One biographer who is very sympathetic to Flexner, Thomas Neville Bonner, made the case in his book about Flexner that when Abraham was growing up in Louisville, Kentucky, it was a time when, while there was certainly nothing akin to equality, there were more services and opportunities for the city's black community than in a lot of other places. There were a dozen schools for black students there when Abraham was growing up, and professional training schools in teaching, medicine, and law were available to black residents. And the Flexners, who were not wealthy, lived in a neighborhood where they had black neighbors. Abraham noted

• 45:23Holly Frey?

  later in his life that he and his siblings often played with the black children in their neighborhood.

• 45:28Tracy V. Wilson?

  This experience may have left Abraham Flexner a little idealistic about the realities of life for the black families that he knew and socialized with. To him, it seemed obvious that any of the kids he played with could grow up to do the same kinds of jobs that he and his siblings could do. But it seems that he didn't really come to terms with the fact that there were plenty of other people who didn't see things this way. He acknowledged during his lifetime that he didn't realize that the black students he had known growing up were so deeply disadvantaged until later in his life when he was researching and analyzing educational institutions.

• 46:01Holly Frey?

  After his retirement from the institute, both before and after World War II, Flexner was pretty outspoken against prejudice. He made a radio broadcast in which he stated his disappointment that democracy hadn't brought more equality to the relationship between races. After the war, he spoke about how far behind England the US was in terms of both religious and racial prejudice.

• 46:23Tracy V. Wilson?

  But his feelings about prejudice are complicated. I'll also say that that's an interesting note about England and the US in terms of religious and racial prejudice.

• 46:36Holly Frey?

  I feel like Flexner always compared the US to European countries he had visited, and he always found the US lacking by comparison. But some of that is definitely a rose-colored glasses situation.

• 46:46Tracy V. Wilson?

  Yeah, yeah. I don't, I don't know when he made that statement, but something that's going to come up in an episode we're going to record shortly is like about racism in England specifically. Anyway, back to the subject at hand. His feelings about prejudice are complicated. Although he had been raised by devout Jewish parents, Abraham and his siblings all drifted away from the Jewish faith, and they considered themselves secular Jews. When he encountered antisemitism, he tended to presume the person involved was ignorant instead of malicious, and he just brushed it off and went on with his life. But he was in a position to be able to do that. Antisemitism doesn't seem to have materially impacted his career or his life.

• 47:31Holly Frey?

  Yeah, this is definitely one of those cases where I think he doesn't realize that he was, you know, enjoying a certain degree of privilege and being able to be like, oh, you don't like me? Okay. I still have plenty of opportunities, which is not how it works for everybody. The true depth of racism against the black community was clearly a blind spot in his work, and that left a lasting legacy on both black physicians and patients that is still felt. He just thought that medical schools and other institutions of higher learning should be admitting students regardless of their sex, color, or religion. But he didn't seem to recognize that there was a whole world of obstacles that had to be addressed to get to the point where students who weren't white or weren't male could even be applying

• 48:12Holly Frey?

  to medical school, let alone get through the admission process. And in a way, it struck me while I was researching this, that his own idealism put him in this situation, not dissimilar to the scientists that he once wrote about, who accidentally advanced the technologies of warfare. In his work for school reform, the already disadvantaged black schools simply could not keep pace with standards that required money and resources they simply didn't have. And white schools were still not often admitting black medical students.

• 48:44Tracy V. Wilson?

  The debate over Flexner's intentions continues among medical historians. And if you start digging, you'll find people who think of him as everything from a benevolent paternalist, we've talked about a lot of those on the show, to inherently racist. We've talked about a lot of those too. And this, this latter part is due to the, the discussion of hygiene as a primary focus for black physicians. There are examples of leaders from both Mahary and Howard using similar language regarding the need for hygiene instruction as an important part of the service of black doctors. They predate Flexner's report by a couple of years.

• 49:20Holly Frey?

  And this is, on its surface, inherently racist. Those leaders who also said that that was an important part of a black doctor's training were also white. But it also suggests that Flexner's statements were echoes of the school's stated missions rather than standalone judgments that he made. And there is also an interesting possibility, as discussed in a 2011 article in the Journal of the History of Medicine and Allied Sciences by Lynn E. Miller and Richard M. Weiss, that this language was actually part of carving out a public health role for the physicians from these schools in an effort to garner support for the schools across racial divides. In the statements from Mahary and Howard in 1907 and 1908 that we're talking about, those sentiments of hygiene being the highest need

• 50:06Holly Frey?

  are followed by mentions of how obvious it is thus that these institutions should be supported.

• 50:11Tracy V. Wilson?

  And there are some indicators that a number of medical schools, black and white, were already in an economic tailspin before Flexner's report was released. Some of that was because there were already efforts to try to meet the guidelines that had been issued by the AMA, and the financial burdens of doing that just proved to be too much to allow for sustainability.

• 50:31Holly Frey?

  While the discussion of Flexner's intentions and the real ramifications of his work continues, the AMA, following the findings of their Ethics Council, did issue a public apology in 2008, quote, "for its past history of racial inequality toward African-American physicians, and shares its current effort to increase the ranks of minority physicians and their participation in the AMA." The organization also announced a number of programs aimed at encouraging minorities to pursue careers in medicine.

• 51:00Tracy V. Wilson?

  This is one of those cases where we're still untangling all the tendrils of all these influences on the medical field that will probably continue for years to come.

• 51:08Holly Frey?

  I wanted to close with another quote from Flexner's usefulness of useless knowledge. "I personally remain in a state of conflict about the man and his work. It's like I want to support an idealist who wants to make things better, but not when that idealism blinds you so much that you end up hurting people. But when I came across this passage while I was researching, it really hit me in its pertinence to our world today." And he wrote, quote, "The justified outcry of those who through no fault of their own are deprived of opportunity and a fair share of worldly goods therefore diverts an increasing number of students from the studies which their fathers pursued to the equally important and no less urgent study of social, economic, and governmental problems.

• 51:52Holly Frey?

  I have no quarrel with this tendency. The world in which we live is the only world about which our senses can testify. Unless it is made a better world, a fairer world, millions will continue to go to their graves silent, saddened, and embittered." That is the complicated Flexner report.

• 52:11Tracy V. Wilson?

  Yeah.

• 52:14Tracy V. Wilson?

  I think it's worth knowing that like, there's a question sometimes where it seems like people are kind of asking, was he racist or was he operating from best intentions?

• 52:26Holly Frey?

  It can be both.

• 52:28Tracy V. Wilson?

  Yeah, if he was operating from his best intentions, like, still racist, though. Like, it's impossible to grow up in a position of privilege in a racist society that is threaded all through with many layers of racist, of racism, and like, to not be racist. Like, it is a lifelong effort to undo all of those thinking patterns, no matter how well-intended you are.

• 52:53Holly Frey?

  Yeah, I mean, it's one of those things, when you read his writing, he so clearly believes that like, if we just shut down all the bad black medical schools, these two good ones are going to be so good that then we can expand from there and everything will be great. And it's like, he's missing so much of the puzzle that, like, again, in an ideal world, sure, but like, um, yeah, he's complicated. I have complicated feelings about him.

• 53:28Tracy V. Wilson?

  Thanks so much for joining us on this Saturday. If you'd like to send us a note, our email address is [email protected]. And you can subscribe to the show on the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows.

• 53:50Holly Frey?

  A rare disease diagnosis can change your life, but it doesn't have to define your future. In season seven of Untold Stories: Life with a Severe Autoimmune Condition, host Martine Hackett continues the conversation with people living with MG, CIDP, and the broader rare disease community, exploring what comes after diagnosis through stories of hope, progress, and connection. Produced by Ruby Studio in partnership with Argenx, listen on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

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